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CHAPTER

56
Tuberculosis
Steven W. Harrison, Frank Ganzhor n and Allen Radner

100,000 annually (1). Political unrest and armed conflict con-

CLINICAL OBJECTIVES tribute to making available treatment almost impossible to
implement in some areas.
1. Cite risk factors for tuberculosis (TB).
2. Summarize an approach to a patient with a positive
TB skin test (TST). RISK FACTORS
3. Describe the evidence-based treatment recommenda-
tions for active and latent TB.
Most cases of tuberculosis in the United States are diagnosed
in minority and foreign-born populations. The more danger-
ous multidrug-resistant (MDR) strains tend to come from
Tuberculosis (TB) is the second-leading cause of death from endemic areas such as Southeast Asia and Africa. In addition
infection in the modern world. Despite effective treatment, to ethnic and immigrant status, risk factors for infection or
the potential for vaccination, and knowledge of improved san- progression include: HIV, other immunocompromised states
itation techniques which prevent spread, the only infection (e.g., cancer, treatment with tumor necrosis factor antago-
that kills more people is HIV. World Health Organization nists), chronic diseases such as diabetes mellitus, bariatric sur-
data from 2005 demonstrate that approximately 9 million peo- gery recipients, injection drug users, personnel who work or
ple worldwide develop active TB every year and more than live in high-risk settings (e.g., prisons, long-term care facilities,
2 million die from the disease (1). hospitals), and children younger than 4 years of age who are
The number of people estimated to have latent tuberculo- exposed to high-risk individuals (7).
sis (LTBI) worldwide is approximately 2 billion. LTBI is
found in people who had exposure to and brief infection with
TB, but resolved the infection. These individuals are no DIAGNOSIS
longer contagious, but the rate of reactivation to active TB is
5% to 10% per lifetime in most individuals and 7% to 10% per In primary care, we see individuals who have undiagnosed TB
year in HIV-positive individuals (2). in many settings. Although routine physical exams of children
There has been a significant resurgence of TB in the third and adults no longer include automatic TB testing, TB sur-
world, primarily associated with the HIV epidemic. In com- veillance is still performed as part of pre-employment exams
parison, US data from the Centers for Disease Control and in many work settings. Most cases found in this manner will
Prevention (CDC) show that there were 14,097 reported cases be LTBI. We must also be alert to the sometimes obvious,
of active TB in 2005 with 640 deaths, for a death rate of 0.2% but frequently subtle findings that lead to the diagnosis of
(3). This is considerably reduced from the 1953 death rate of active TB.
12.4% (4). The accurate diagnosis of active TB becomes more diffi-
TB was described by Hippocrates as consumption around cult among patients with HIV because of the presence of non-
460 BC (5). At the time, it was the most widespread disease in tuberculous mycobacteria. In addition, HIV infection can
the world and almost always fatal. His advice to his fellow cause anergy and therefore a false-negative TST. Nucleic acid
physicians was not to visit patients in the later disease stages amplification testing (NAAT) can be used in an attempt to dif-
because they would inevitably die and damage the reputation ferentiate TB from other mycobacterial infections (8),
of the treating physician. although AFB culture is considered the gold standard. The
TB remained a leading cause of death in the developed CDC recommends repeat TST or chest x-ray (CXR) in HIV-
world until the early 20th century. Public health measures positive individuals after beginning highly active anti-retrovi-
decreased spread of disease. Sanitariums were established in ral therapy (HAART), because these tests may turn positive
the 1850s as the first real step in TB treatment. BCG vaccine, after the individual’s immune function improves with
which can prevent up to 50% of TB cases (6), was first released treatment (9).
in 1921 and came into widespread use in 1945. In 1943, the first
effective medication (streptomycin) was discovered (6). Latent Tuberculosis Infection
Treatment and eventual eradication of TB is complicated LTBI is distinguished from active TB by history and test
by lack of resources in less developed countries, specifically in results (Fig. 56.1). Positive TST or interferon gamma release
sub-Saharan Africa where there are more than 300 cases per assay (screening blood testing) combined with a negative CXR

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660 PA R T I I I • C O M M O N P R O B L E M S

hemoptysis, and malaise. Later in the disease course, patients

Positive screening test (skin test may develop a nonproductive cough or cough with purulent
(TST) or IFN-g relase assay)
sputum. Cough lasting more than 2 or 3 weeks with one addi-
tional symptom as previously mentioned should trigger suspi-
cion for TB. TB should also be suspected in a patient who falls
Obtain chest x-ray and sputum into a high-risk group with unexplained illness, including res-
for AFB piratory symptoms of more than 2 to 3 weeks’ duration (11).
Pulmonary TB is generally accompanied by symptoms of
chest pain, weight loss, fatigue, and anorexia. Examination of
Chest x-ray and AFB negative? the lungs can reveal crackles and rhonchi. Hemoptysis, seen
later in the disease course, usually accompanies cavitary dis-
Equivocal ease (Fig. 56.2) (2). Dyspnea and hypoxia are signs of signifi-
Positive Negative findings? cant pulmonary involvement. Patients with extensive disease
may develop acute respiratory distress syndrome.
Diagnose activeTB Latent TB Further testing* Miliary TB (now considered synonymous with dissemi-
nated TB) refers to the classic finding of diffuse (millet) seedlike
appearing (reticulonodular) patterns on plain CXR (Fig. 56.3).
Negative AFBs
This results from hematogenous spread of infection; multiple
sites are potentially involved. Pulmonary involvement is com-
*Can include CT scan, induced sputums or gastric aspirates,
mon but not universal (12).
bronchoscopy with biopsy and or washings among others. TB can also invade other organ systems. Most lymph node
Consultation and/or referral should be considered (e.g., disease is manifested as enlarged cervical nodes and accounts for
Infectious Disease and Pulmonology). approximately 40% of non-pulmonary cases. Genitourinary dis-
ease (kidneys, ureters, bladder, or genitals) accounts for about
Figure 56.1 • Workup of patients with a positive
15% of non-pulmonary disease. Patients with bone and joint
screening test for tuberculosis.
disease (about 10% of extrapulmonary cases) present with pain
in the affected area. Spinal column disease (commonly known
as Pott disease) causes back or neck pain as vertebra and discs
and lack of symptoms establishes the diagnosis of LTBI (10). are destroyed by infection. Patients with Pott disease often have
In patients with a positive CXR or computed tomography constitutional symptoms such as fever or weight loss and some-
(CT) scan or suggestive symptoms, three negative AFB cul- times neurologic symptoms (spinal cord compression). Plural
tures are required before diagnosing and treating a patient for and pericardial disease can also be seen but are infrequent.
LTBI rather than active TB. TB meningitis has a high mortality rate (about 40%) and
significant morbidity. Unlike bacterial forms of meningitis, TB
Differential Diagnosis meningitis often begins with vague symptoms of fatigue, irri-
The diagnosis of TB requires a high index of suspicion. tability, and anorexia for weeks, followed by stiff neck, vomit-
Manifestations of active TB can be classified as pulmonary ing, and headache (13). Young children (4 years and younger)
(about 80% of cases) or extrapulmonary. Clinical features of and immunocompromised individuals are at increased risk.
pulmonary infection are described under the history and phys- This form of the disease is fatal without treatment.
ical examination section in this chapter.
The differential diagnosis for pulmonary TB includes bac- Laboratory Testing
terial or viral pneumonia, nontuberculous mycobacterium, sar- Laboratory investigation for TB usually begins with TST
coidosis, aspiration pneumonia, lung abscess, fungal infections with purified protein derivative (PPD). This test does not dis-
such as coccidiomycosis and histoplasmosis, Wegener granulo- tinguish between LTBI and active TB, but is used to detect
matosis, actinomycosis, and cancer. The clinical exam is inade- both in exposed or high-risk individuals. The interpretation of
quate for differentiating between these possibilities and further the test (induration or size of the wheel at the inoculation site)
testing must be performed. Table 56.1 lists some clinical and depends on the patient’s underlying risk status (Table 56.2).
laboratory features for differentiating these conditions. After a patient has a positive TST or a positive blood test by
Extrapulmonary TB results from blood borne (hema- interferon gamma release assay (IFN-g), sputum tests for acid
togenous) spread from primary disease or reactivation of latent fast bacilli (AFB) and/or body fluid/biopsy analysis by poly-
infection. In order of decreasing frequency, sites for active TB merase chain reaction (PCR)/NAAT are obtained (14,15). The
infection include: lung, lymph nodes, pleurae, genitourinary test characteristics for these studies are shown in Table 56.3. Both
tract, bone, brain (meningitis and other central nervous system AFB culture or PCR /NAATs are highly specific, and when pos-
involvement), and peritoneum (2). Disseminated or miliary itive rule in disease (LR! 10 or higher). A tissue diagnosis by
TB involves the lung or multiple sites. bronchoscopy or pleural biopsy may be needed if noninvasive
testing does not lead to a definitive diagnosis (10,13,16,17).
History and Physical Examination If the patient is from a country that administers BCG
Primary active TB may present as atypical pneumonia with vaccine, a false-positive skin test result may have occurred.
fever, nonproductive cough, and positive CXR findings (see Interestingly, even if the subsequent CXR is negative, the
Fig. 56.2). Reactivation TB, however, is more common; symp- patient could have LTBI and should be treated as such, per
toms include fever, chills, night sweats, anorexia, weight loss, CDC guidelines.
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CHAPTER 56 • TUBERCULOSIS 661

TA B L E 5 6. 1 Differential Diagnosis of Active Pulmonary Tuberculosis

Frequency Distinguishing
Diagnosis Typical Features (US Data) Features Mortality
Pulmonary TB Abnormal chest x-ray 4.4/100,000 Positive PPD 0.2/100,000
(80% reactivation) Cough, fever, anorexia nationwide Positive AFB (smear,
(20% primary) Pneumonia culture, or biopsy)
Positive PCR or
IFN-$ assay
Coccidiomycosis Location in Southwest 91/100,000 Positive serology or Mostly self-limited
Fatigue in Arizona culture
Pneumonia Lung biopsy
E. Nodosum PCR
Cryptococcosis Productive cough Rare (96% of cases Positive serology 12%–28%
Hemoptysis in those with or culture
Weight loss if HIV HIV) CSF studies
infected nationwide Lung biopsy
Histoplasmosis Pneumonia 22% of population Positive serology or 7%–23% (dissemi-
Dysphagia have positive culture nated disease)
Cavitary disease antibodies Immunodiffusion test
Cough nationwide Lung biopsy
Enlarged mediastinal
nodes
Neoplasm Smoker 219,000 new cases Sputum cytology 10% 5-year survival,
(lung cancer) Cough per year Lung biopsy overall
Hemoptysis 0.06% nationwide PET/CT scan Up to 35%–40% sur-
Shortness of breath vival with successful
Chest pain complete resection
Sarcoid Shortness of breath, 10–20/100,000 Biopsy (non-caseating 5–10%
cough nationwide granulomas)
Skin lesions Serum ACE level
Hilar adenopathy PET scan
Diffuse lung disease Diagnosis of exclusion
Wegner Fatigue #1/200,000 c-ANCA/p-ANCA 80% survival at
granulomatosis Sinus pain nationwide Lung biopsy 6–24 months
Cough
Rhinorrhea
Actinomycosis Cough 1/60,000 nation- Culture Treatment prevents
Hemoptysis wide Lung biopsy mortality
Sinus drainage Sulfa granules in
Chronic soft-tissue nasal discharge
swelling of the
head and neck
ACE " Angiotensin Converting Enzyme; AFB " acid-fast bacilli; c-ANCA " classical anti-neutrophil cytoplasmic antibodies; p-ANCA " Perinuclear
Anti-Neutrophil Cytoplasmic Antibodies; CT " computed tomography; PET " positron emission testing; PPD " purified protein derivative; TB "
tuberculosis.

Patients who are immunosuppressed may not produce a meningitis. Pleural biopsy and thoracentesis are recommended
delayed type hypersensitivity reaction on PPD testing; these for diagnosing pleural TB. CT-guided needle biopsy is used to
patients should undergo initial TST. If the TST is negative, diagnose internal organ disease (e.g., adrenal glands) and
particularly if HIV-positive, it may still be reasonable to pur- osteomyelitis. A simple culture can be used to diagnose renal
sue further screening using NAAT and standard sputum test- disease, suggested by “sterile pyuria.” There are many published
ing to rule out active TB (2,18). protocols that guide evaluation and treatment including the
TST and sputum analysis also play a major role in the NICE is National Institute for Health and Clinical Excellence
diagnosis of extrapulmonary TB, if positive. Spinal fluid analy- (NICE), CDC guidelines (includes the American Thoracic
sis and culture/NAAT are suggested for the evaluation of TB Society recommendations), and Canadian guidelines (13,15,19).
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662 PA R T I I I • C O M M O N P R O B L E M S

TA B L E 5 6 . 2 Defining a Positive Tuberculosis

Skin Test by Risk Status

Positive Purified
Protein Derivative
Reading (Elevation
Risk Status of Wheel)
High Risk %5 mm
HIV infection
Recent contacts of infectious
tuberculosis cases
People with chest x-ray
findings of prior tuberculosis
Organ transplant recipients
Immunosuppressed for
other reasons
Taking %15 mg of prednisone
daily
Taking tumor necrosis
factor-& antagonists
Moderate Risk %10 mm
Recent immigration from
high prevalence area
Residents or employees of
health care facilities or
shelters/prisons, etc.
Children younger than 4 years
of age
Figure 56.2 • Chest x-ray showing cavitary lesion and Children or adolescents
surrounding infiltrate (seen with reactivation disease). exposed to adults at high risk
of disease
Injection drug users
Imaging
Low Risk %15 mm
A CXR is the imaging test of first choice (9). This test is widely
No risk factors
available and associated with markedly less radiation exposure
than CT (Fig. 56.4). The sensitivity and specificity vary depend- Information from: www.cdc.gov/tb/publications/factsheets/testing/skintesting.
ing on the setting and pretest probability. CT scans provide htm

significantly more detail, but don`t always obviate the need for
a tissue diagnosis and should be reserved for cases when the
diagnosis is unclear by CXR alone.
The CXR classically shows upper lobe infiltrate with cav-
itation (Fig. 56.2), but any pattern may be seen ranging from a
solitary nodule to diffuse infiltrates representing bronchogenic
spread. The CXR pattern in children often shows an infiltrate
with hilar and paratracheal lymphadenopathy.

TREATMENT
The most common presentation in a primary care office is a
patient who has a positive TST and a negative CXR. This
patient most likely has LTBI; however, single drug treatment
should not begin until active TB disease has been excluded.
For those suspected of having active TB, the recommended
multidrug regimen should be started as described below until
the correct diagnosis is established. Directly observed therapy
(DOT) is the standard of care in many areas and is generally
Figure 56.3 • Chest x-ray showing miliary tuberculosis. supervised by the local health department. Unfortunately,
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CHAPTER 56 • TUBERCULOSIS 663

TA B L E 5 6 . 3 Available Tests and Test Characteristics for Diagnosing Active Pulmonary Tuberculosis
Common
Test Abbreviation Sensitivity Specificity LR! LR"
†
Tuberculin skin test PPD 59%–100% 44%–100% 1.8 to high 0.9 to low†
Chest x-ray CXR 38–67% 59%–74% 0.9–2.6 1.1–0.5
Computerized CT 96% 50% 1.9 0.08
tomography
Acid-fast bacillus smear AFB (smear) 50%–96% 98% 25–48 0.51–0.04
Acid-fast bacillus AFB (culture) 93%–97% 98% 46.5–48.5 0.07–0.03
culture and sensitivity
Polymerase chain PCR* 95% 98% 47.5 0.05
reaction assay
Interferon gamma Quantiferon 70%–90% 93%–99% 10.0–90.0 0.3–0.10
release assay Gold/TB spot
Bronchoscopy Bronc 73%–94% 92%–100% 9.1 to high† 0.29 to low†
LR! " positive likelihood ratio; tests with higher values, especially '10, are good at ruling in disease; LR( " negative likelihood ratio; tests with lower
values, especially #0.1, are good at ruling out disease.
*Some nucleic acid amplification testing falls into this category.
†
Ratio includes a zero in the denominator; undefined.
Information from: Escalante P. In the clinic. Tuberculosis. Ann Intern Med 2009;150(11):ITC61–614; Canadian Tuberculosis Standards. 6th Edition. 2007.
Available at www.phac-aspc.gc.ca/tbpc-latb/pubs/pdf/tbstand07_e.pdf.

although DOT is frequently recommended as a method for

improving adherence, a Cochrane review did not find DOT
superior to self-administration of treatment with respect to
cure or treatment completion (20).
TB is a reportable disease and the public health depart-
ment (PHD) is tasked with its diagnosis and treatment nation-
wide. The PHD is a great resource and can guide or take over
the treatment of any patient with TB, especially complicated
patients. In all cases, the PHD is ultimately responsible for
ensuring availability of appropriate diagnostic and treatment
services and for monitoring the results of therapy. The other
resources available to you vary by location, patient`s insurance
and citizenship, and specialty availability; but include the local
and regional infectious disease and pulmonary specialists.
You should obtain a list of the patient’s current medica-
tions to avoid drug interactions. Some interactions to note
include (16):
• Isoniazid (INH) increases blood levels of phenytoin
(Dilantin) and disulfiram (Antabuse)
• Rifampin decreases blood levels of oral contraceptives, war-
farin, sulfonoureas, and methadone
• Rifampin is contraindicated in HIV-infected individuals
treated with protease inhibitors and most nonnucleoside
reverse transcriptase inhibitors
LTBI
To determine whether an individual who has a positive TST
or IFN-$ assay result is a candidate for treatment of LTBI, the
CDC recommends determination of the benefits of treatment
by evaluating individual’s risk for developing active TB in
addition to his or her commitment to complete a course of Figure 56.4 • Computed tomography scan showing
treatment and the resources available to ensure adherence; in upper lobe disease and mediastinal adenopathy.
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664 PA R T I I I • C O M M O N P R O B L E M S

Figure 56.5 • Algorithm to guide

High clinical suspicion for active TB
duration of continuation-phase
treatment for culture-positive
tuberculosis patients. TB "
tuberculosis; INH " isoniazid; RIF " Place patient on initial-phase regimen:
Rifampin; EMB " ethambutol; PZA " INH, RIF, EMB, PZA for 2 months
pyrazinamide; CXR " chest X-ray;
HIV " human immunodeficiency
virus.

Is
specimen collected
No at end of initial Yes
phase (2 months)
culture positive?

Give continuation-
phase treatment of
INH/RIF daily or twice Was
weekly for 4 months there
No cavitation Yes
on initial
CXR?
Give continuation-
Is the phase treatment of
No patient HIV Yes INH/RIF daily or twice
positive? weekly for 7 months

Give continuation- Give continuation-

phase treatment of phase treatment of
INH/RIF daily or twice INH/RIF daily for
weekly for 4 months 7 months

general, most patients with positive tests are treated (21). In Pyridoxine (B6) is usually given at 25 mg orally daily to
patients who may have a false-positive TST because of prior prevent neuropathy.
BCG vaccination, treatment for LTBI is recommended • Rifampin daily for 4 months; primarily considered for
because the vaccination is only effective in up to 50% of cases patients who have isoniazid-resistant TB or allergy.
and only lasts approximately 15 years. There is no way to reli-
ably distinguish false from true-positive tests. Active TB
Treatment for a variety of conditions is often deferred For adult patients with active TB, there are four drugs used
until therapy for LTBI (or active TB) is in progress. Specific for initial treatment, with different options for dosing dura-
examples are deferral of HAART until latent or active TB tion in a continuation phase as follows:
therapy is started and deferral of tumor necrosis factor antag-
• Two-month initial treatment phase: INH, rifampin (RIF),
onists in RA until near completion of therapy (for LTBI or
pyrazinamide, and ethambutol.
active TB) (9). A Cochrane review supports treatment of LTBI
• Four-month continuation phase with INH and RIF (daily
in patients with HIV to prevent active disease (22). Finally, the
or twice weekly); treatment is extended to 7 months (daily
CDC recommends therapy for children younger than age 5
or twice weekly) for patients with cavitary pulmonary TB
years and severely immunocompromised individuals with
who remain sputum-positive after initial treatment, if preg-
high-risk exposures and negative TSTs, pending re-evalua-
nant, if HIV-positive, or in patients with concurrent silico-
tion by sequential testing in 8 to 10 weeks (9).
sis to prevent relapse. An algorithm to guide treatment of
For adult patients with LTBI, the CDC recommends the
patients with high clinical suspicion of active TB is shown
following options:
in Figure 56.5.
• Isoniazid for 9 months; twice-weekly regimens or 6-month • Two months’ continuation therapy with INH and RIF is given
therapy (daily or twice weekly) may be considered. for patients who remain culture negative and evaluation at
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CHAPTER 56 • TUBERCULOSIS 665

Figure 56.6 • Algorithm to guide treat-

High clinical suspicion for active TB
ment of culture-negative tuberculosis.
despite negative smears based on:
TB " tuberculosis; INH " isoniazid; RIF "
Abnormal chest x-ray Rifampin; EMB " ethambutol; PZA " pyrazi-
Clinical symptoms namide
No other diagnosis
Patient placed on initial phase
regimen: INH, RIF, EMB, PZA for
2 months

Is
No initial culture Yes
positivie?

Continue treatment
for culture-positive TB
Was there
symptomatic or
No chest x-ray Yes
improvement after
2 months of
treatment?

Discontinue treatment Give continuation-phase

treatment of IHN/RIF
Patient presumed to
daily or twice weekly
have LTBI
for 2 months

2 months reveals clinical and CXR response to antitubercu- tuberculosis led to a higher incidence of relapse in HIV-pos-
losis drug therapy. An algorithm to guide treatment for cul- itive patients (24).
ture-negative TB is displayed in Figure 56.6.
• To prevent isoniazid-related neuropathy, pyridoxine 10 to Extrapulmonary TB
25 mg/d is given, especially to those at risk for vitamin B6
The basic principles underlying pulmonary TB treatment
deficiency (e.g., alcoholic, malnourished, pregnant or lactat-
also apply to extrapulmonary forms of the disease. Although
ing women, HIV-positive patients, and those with chronic
relatively few studies have examined treatment of extrapul-
diseases).
monary TB, evidence suggests that 6- to 9-month regimens
that include INH and RIF are effective. The exception to
Drug-resistant TB disease is caused by Mycobacterium
this is infection of the meninges for which a 9- to 12-month
tuberculosis organisms that are resistant on susceptibility
regimen is recommended. Prolongation of therapy is consid-
testing to at least one first-line anti-TB drug. MDR TB is
ered for any patient with TB in any site that is slow to
resistant to more than one anti-TB drug and at least INH
respond to treatment (15).
and RIF. MDR TB is treated with a variety of injectable
drugs including streptomycin, kanamycin, and amikacin or
oral drugs including fluoroquinolones, ethionamide,
cycloserine, and para-aminosalicylic acid PAS (23). In a OUTPATIENT INFECTION CONTROL
Cochrane review of 11 small trials on the use of fluoro-
quinolones in TB regimens, investigators found no differ- The CDC has published consensus-based recommendations to
ence in trials substituting ciprofloxacin or ofloxacin for prevent spread of disease (19). It states that people with TB
first-line drugs in relation to cure, treatment failure, or clin- should not be routinely admitted to the hospital for diagnostic
ical or radiological improvement; however, substituting tests or care and that those with respiratory TB should be sep-
ciprofloxacin into first-line regimens in drug-sensitive arated from immunocompromised patients (25).
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666 PA R T I I I • C O M M O N P R O B L E M S

TA B L E 5 6 . 4 Potential Side Effects and Adverse Reactions of Anti TB Medications

Side Effect or
Medication Adverse Reaction Signs and Symptoms
Any drug Allergy Skin rash
Ethambutol Eye damage Blurred or changed vision
Changed color vision
Isoniazid, Hepatitis Abdominal pain
pyrazinamide, Abnormal liver function test results
or rifampin Fatigue
Lack of appetite
Nausea
Vomiting
Yellowish skin or eyes
Dark urine
Isoniazid Peripheral neuropathy Tingling sensation in hands and feet
Pyrazinamide Gastrointestinal Upset stomach, vomiting, lack of appetite
intolerance Joint aches
Arthralgia Gout (rare)
Arthritis
Streptomycin Ear damage Balance problems
Kidney damage Hearing loss
Ringing in the ears
Abnormal kidney function test results
Rifamycin Thrombocytopenia Easy bruising
• Rifabutin Gastrointestinal Slow blood clotting
• Rifapentine intolerance Upset stomach
• Rifampin Drug interactions Interferes with certain medications,
such as birth control pills, birth control
implants, and methadone treatment

Patients who have suspected or confirmed TB should be TREATMENT MONITORING

considered infectious if they are coughing or have positive spu-
tum smears for AFB and are not receiving adequate antituber- Baseline and routine laboratory monitoring, such as liver func-
culosis therapy, have just started therapy, or have a poor clinical tion tests, during treatment of LTBI are indicated only for
or bacteriologic response to therapy (25). The most contagious patients with a history of liver disease, HIV infection, pregnancy
forms of TB are those that cause airborne spread. TB of the lar- (or within 3 months after delivery), or regular alcohol use (16).
ynx and tuberculosis with cavitary disease (Fig. 56.2) and Clinical monitoring, including a brief physical examination,
hemoptysis tend to be the most contagious. Patients are consid- should occur at monthly visits to assess adherence and identify
ered contagious until they have been on adequate chemother- signs or symptoms of adverse drug reactions (Table 56.4).
apy for a minimum of 2 weeks, have three negative AFB spu- The following tests should be obtained to monitor treat-
tum cultures (collected in 8- to 24-hour intervals with one early ment effect in people with active pulmonary TB (15):
morning specimen), and show clinical improvement.
TB is not spread through direct contact, sharing food, or • Monthly sputum for AFB smear and culture (until two con-
kissing. It is not necessary to separate an infectious person on secutive negative cultures)
treatment from other household contacts. Young children, • Serial sputum smears every 2 weeks to assess early response
however, who are close contacts can be given chemopro- • Additional drug-susceptibility tests if culture-positive after
phylaxis to avoid separation from a parent. During the first 3 months of treatment
2 weeks of treatment for patients with smear positive pul- • Repeat CXR obtained at completion of initial treatment
monary, laryngeal or respiratory tract disease patients should phase for patients with initial negative cultures and at end of
avoid unnecessary contact with people from outside the treatment for patients with culture-negative TB. CXR is not
household. This will include exclusion from work, day care necessary for patients with culture-positive TB
facilities, or schools. • Follow-up laboratory testing for renal function, liver function,
Patients should remain noninfectious if regular, adequate and platelet count if abnormalities were noted at baseline.
chemotherapy is continued, even though bacilli might still be • Visual acuity and color vision monthly if ethambutol is used
seen in sputum smears. '2 months or in doses '15 to 20 mg/kg
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CHAPTER 56 • TUBERCULOSIS 667

• For patients with LTBI, the CDC recommends isoniazid

KEY POINTS for 6 to 9 months and pyridoxine (B6) to prevent neuropa-
• Limit TB screening to those at higher risk of disease includ- thy OR rifampin daily for 4 months (primarily considered
ing minority and foreign-born populations, HIV infection or for patients who have isoniazid-resistant TB or allergy).
other immunocompromised states, chronic diseases, bariatric • For patients with active TB, four drugs (isoniazid,
surgery recipients, injection drug users, personnel who work rifampin, pyrazinamide, and ethambutol) are used for
or live in high-risk settings, and children younger than 4 initial treatment for 2 months, with different options for
years of age who are exposed to high-risk individuals. dosing duration in a continuation phase based on risk
• TB skin testing and interferon gamma release assays (IFN- $) factors for relapse.
are equivalent screening tests, although IFN-$ may be • Tuberculosis is reportable to the PHD in your area; the
more accurate in discriminating patients who have TB PHD is charged with TB treatment and eradication
from those who have a positive skin test for other reasons. nationwide and is an excellent resource. Local and
• Obtain a CXR and sputum for AFB after a positive TB regional pulmonology and infectious disease specialists are
skin test result to distinguish LTBI from active TB before also excellent resources for consultation and numerous
beginning treatment; a negative CXR and lack of symp- online resources are available to assist in the diagnosis and
toms establishes the diagnosis of LTBI. management of TB.